Family physicians have always done what they can to care for those whose means of obtaining health care are inadequate. Such generosity has enriched, and literally saved, many persons’ lives. Sadly, though, the number of US citizens unable to pay for health care is increasing, and individual physician goodwill will not solve the problem. A comprehensive solution is needed, and that depends on restoring health to the currently paralyzed national political process.
If you are inclined to become more involved in pursuing efforts to address the issue in political, social, and educational spheres, you will find help in this article, which summarizes the problem and reviews health policy options being considered and their implications for our patients. You will also find resources through which you can make your voice heard.
Scope of the problem
The US is the only country in the developed world without a national program for health insurance for all its citizens. Though we spend over $1.7 trillion on health care, the number of uninsured people in 2004 was about 46 million, almost 16% of the population. In 2000, 40 million people (14%) were uninsured.1 The premise of consumer-driven care is that patients who pay more of the true cost of their care will become more prudent purchasers of health services.
Critics argue that increasing out-of-pocket costs (deductibles and co-pays) acts as a deterrent to seeking appropriate care, particularly for the less well off; that wealthy and healthy people will purchase these policies, thus increasing the costs of caring for those left in the traditional insurance system; and that such a system preserves the inefficient and wasteful private insurance industry.
Government as the single payer, not employer, of health care. Proponents argue that administrative cost savings in such a system (no or minimal private health insurance) will more than cover the cost of care for the uninsured.
Web resources
Web resources for information on the uninsured and other health policy topics:
Kaiser Family Foundation: www.kff.org
Cover the Uninsured campaign: www.covertheuninsured.org
Health policy for students and faculty: www.KaiserEdu.org
Physicians for a National Health Plan (single-payer advocates): www.pnhp.org
Opponents of this idea argue it will lead to long lines for specialty care (read: Britain and Canada) and stifle innovation. Considering the US spends almost 50% more of its GDP on health care than does Canada and almost double what Britain spends, it seems unlikely our experience will parallel those countries. Ironically, in a system such as Canada’s, where most care is delivered by private practice physicians, there is almost certainly less administrative burden on physicians than they currently experience in the US.
A system of health care vouchers as recently proposed by Emanuel and Fuchs. Their plan would preserve the private insurance system, phase out Medicare, Medicaid, and employer-based insurance, include Federal oversight of the benefit package and technology assessment, and be funded by an earmarked value-added tax. It attempts to achieve administrative savings and a more equitable system of care, while not challenging the current substantial role of the private insurance sector. Pay-for-performance: What can you expect?”, J Fam Pract 2005; 54[7]:609) exemplify this effort. Certainly, efforts at improving care quality are worthwhile as our health system has too much practice variability as well as over- and underutilization of care. However, it is difficult to believe that such efforts will control costs enough to allow for the expansion of health insurance rates.
Where to go from here
Given past failures at expanding health care to all, many observers are resigned to the incrementalist approach such as expanding small business insurance by pooling risk, perhaps controlling costs through consumer-driven care and pay-for-performance programs, and dealing more effectively with malpractice problems (high premiums and defensive medicine). Most would agree, however, that such efforts will not make a serious dent in the uninsured problem.
The continual increase in the number of uninsured in a country as wealthy as ours is a national tragedy and is tremendously frustrating, particularly for family physicians who constantly see the negative health effects. Physicians need to become better informed about health policy and its implications for our patients and more actively work in political, social, and educational spheres to help move the political process out of its current paralysis to address the uninsured problem.
For information on the uninsured and other health policy topics, and for adding your voice to the debate, see Web resources.
CORRESPONDING AUTHOR
Eric A. Henley, MD, MPH, Department of Family and Community Medicine, University of Illinois College of Medicine at Rockford, 1601 Parkview Avenue, Rockford, IL 61107-1897. E-mail: ehenley@uic.edu